Sample implementation procedure (ADA)



Oregon Military Department

REASONABLE ACCOMMODATION REQUEST

The Americans with Disabilities Act (ADA) protects qualified individuals with disabilities from employment discrimination. Reasonable accommodation is a key nondiscrimination requirement under the ADA. All requests are handled on a case-by-case basis.

Section 1. ACCOMODATION REQUEST

To be completed by the Employee. Please type or print clearly. Attach additional sheets if necessary. If you need help completing this form, contact Micky Dryden, ADA Coordinator at Micky.D.Dryden@mil.state.or.us, (503) 584-3865.

|Name: Last First MI |Employee Identification Number (EIN): |

| | |

| |OR |

|Employee Classification Title: |Section/Work Unit: |

|Work Location (Number and Street Name): |Work Telephone Number: |

| | |

|City State Zip |Supervisor Name: |

|Code | |

1. Identify and describe your impairment. Please attach your medical documentation to this form.

2. How does your impairment affect your ability to do your job?

3. What is your accommodation request? (What do you need to help you do your job?)

Under the ADA, when an employee makes a request for an accommodation, the employer is required to enter into an interactive process. A medical examination may be required to determine if an individual has a disability covered by the ADA and is entitled to an accommodation, and, if so, to help identify an effective accommodation based on the essential functions of your position. When an individual qualifies for reasonable accommodation, the employer is free to choose among effective accommodations, and may choose one that is less expensive or easier to provide

My signature indicates my permission for my medical practitioner(s) to release such information as applicable to and for the evaluation of my request for accommodation and for the agency to contact my medical practitioner(s) to seek additional or clarifying information. The information provided by me is true and correct to the best of my knowledge.

|Employee’s Signature |Date |

Please return this form to the agency ADA Coordinator, HR Director, or your supervisor.

Section 2. REQUEST ACKNOWLEDGEMENT

|Name and Signature receiving request |Date and time request received |

Section 3. INTERACTIVE PROCESS

To be completed by the ADA Coordinator in cooperation with HR and the employee’s supervisor.

Please attach the Job Description, the Essential Job Functions Form, and any other relevant document to this form. For assistance, refer to the HR Department ADA Procedures, or contact Micky.D.Dryden@mil.state.or.us, (503) 584-3865.

Checklist:

□ Meeting with ADA Coordinator and employee’s supervisor to review essential functions and completion of essential job functions form, as needed

□ Meeting with employee to discuss precise job-related limitation imposed by the employee’s disability and how those limitations could be overcome with a reasonable accommodation.

□ Request medical certification from medical practitioner(s), as necessary

□ Identify accommodation options

□ Determine which of the accommodation options are reasonable and do not create an undue hardship.

If the accommodation(s) are deemed reasonable, consider the preference of the requesting employee and select and implement the accommodation that is most appropriate for both the employee and the employer.

Accommodation recommended for implementation:

Section 4. AUTHORIZATION

To be completed by the Agency Appointing Authority or designee.

1. The request for accommodation is: ( ) Approved ( ) Denied ( ) Other

2. If denied, state the justification for denial.

|Name and Signature |Date |Work Telephone Number |

| | | |

Departments: Please forward the completed form and attachments to:

Adjutant General Personnel Office

Attn: Micky Dryden, ADA Coordinator

POBox 14350

Salem, Oregon 97309-5047

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